Provider Demographics
NPI:1316653108
Name:WHITNEY, LOGAN
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:WHITNEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:243 ALPHA AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40218-3205
Mailing Address - Country:US
Mailing Address - Phone:502-272-0049
Mailing Address - Fax:
Practice Address - Street 1:8134 NEW LA GRANGE RD STE 102
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-4677
Practice Address - Country:US
Practice Address - Phone:502-272-0049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-25
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY282793106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist